Mental Health of Syrian Refugees in Jordan

Many refugees that cross the border are young children, escaping violent conditions in Syria. Source: European Commission DG ECHO

When Syrian refugees cross the border to Jordan, their physical injuries are clearly evident. The mental injuries that they have incurred, on the other hand, are far less apparent.1 It is estimated that, on average, more than 50 percent of refugees worldwide manifest mental health problems ranging from chronic mental disorders to trauma, distress, and great suffering.2 Close proximity to horrific events and the loss of loved ones can result in post-traumatic stress disorder and clinical depression, among other psychiatric disorders. However, these mental issues often go untreated because aid workers are overwhelmed with imminent physical injuries. Yet, when left unchecked for long periods of time, the mental issues developed during war and the relocation that often follows may evolve into schizophrenia or another serious psychiatric disorder.3 The public health community must work towards reversing the tide of mental illness among Syrian refugees by increasing immediate treatment, involving local psychiatrists, and training these psychiatrists in mental health wellness programs to create a “new normal” for refugees.

Refugees are persons who flee their home country to escape conflict, an experience that can leave them mentally scarred. The term refugees may include asylum seekers—those who leave their country to avoid prosecution—and internally displaced persons—people who are forcibly displaced to another site within their home country.4 As of June 2014, Syria was the leading country of origin for asylum seekers, according to the United Nations High Commissioner for Refugees (UNHCR).5 Many of the refugees who travel from Syria to Jordan have witnessed or been subject to torture, murder, kidnappings, and sexual assault.

An assessment of the mental health and psychological needs of displaced Syrians in Jordan revealed persistent fear, anger, lack of interest in life, and hopelessness. Roughly 26 percent felt “so hopeless they did not want to carry on living” and nearly 19 percent felt “unable to carry out essential activities for daily living because of feelings of fear, anger, fatigue, disinterest, hopelessness, or upset.”6 Children who were asked to draw a “safe place” in counseling groups seemed to be unable to access any nonviolent memories; instead they drew tanks and soldiers. According to the UNHCR Jordan Health Unit, there were 10,911 cases of mental health illnesses in UNHCR-supported clinics in the first half of 2014. Of those cases, 24 percent were patients with severe emotional disorders, 16 percent had epilepsy and seizures, and 7 percent had psychotic disorders.7 These statistics demonstrate an urgent need for better mental health care for the displaced Syrian population.

According to a study about the mental health of Syrian refugee children, adults are more likely to suffer mental health ailments than children. This is because a child’s body is more likely to demonstrate resilience in the face of outstanding circumstances.6 According to Rutter et al., “Resilience does not constitute an individual trait or characteristic… Resilience involves a range of processes that bring together quite diverse mechanisms operating before, during, or after the encounter with the stress experience or adversity.”8 In a twelve-year study of 31 adolescents who survived the horrors of the Pol Pot regime in Cambodia, 50 percent initially demonstrated PTSD, as opposed to 35 percent in a follow-up study. Similarly, an initial 48 percent demonstrated depression, with only 14 percent in the follow-up. This study presents a strong example of the ability of children and young adults to adjust to severe life situations. However, for these adjustments to be completely successful, they require the intervention and help of a team of mental health experts who begin treatment immediately after children flee their countries.8

Source: SpaceShoe

Considering the importance of mental health treatment, it is tragic that the burden of mental disorders is likely to be undervalued due to a poor understanding of the connection between mental health and other physical health conditions. Health services are not provided equitably to people with mental disorders; inequality of access to treatment is greatest in developing countries like Jordan. This is dangerous because mental disorders increase one’s risk for communicable and non-communicable diseases, and contribute to injury.9 Mental illnesses increase patients’ risk of contracting infectious diseases, according to recent research by Prince et al. For example, is estimated that people with schizophrenia die on average 25 years earlier than people with similar backgrounds who do not have the disorder. Premature death in these individuals occurs due to high rates of suicide, acute and chronic lower respiratory tract illnesses, chronic cardiovascular disease, and diabetes.10 Mental health and physical illnesses are co-morbidities; depression can cause physical illness, and the persistence of physical illness can cause depression. Refugees are at heightened risk for both.

Though they may be less obvious as time passes, mental health issues persist if not treated, especially among adults. A study conducted by Hermasson et al., investigated the mental health of war-wounded refugees after they had spent at least eight years in Sweden. The study included 44 war-wounded refugee men between the ages of 24 to 54 from 9 different countries around the world. Their mental health was assessed using three instruments: HSCL-25, PTSS-10, and a well-being scale. The HSCL-25 is the Hopkins Symptoms Check List-25, which is a commonly used screening instrument designed to identify common psychiatric symptoms; and PTSS-10 is a scale used to assess the presence of Post-Traumatic Stress Disorder. According to the HSCL-25 test results, 43 percent of war-wounded refugees in the study had scores indicating both anxiety and depression. Using the PTSS-10 test, 50 percent of participants indicated at least a “quite severe reaction.” General well being, which was measured by the Well-Being scale, did not improve significantly over time, even though 20 percent of the men sought treatment for psychiatric reasons. This study supported previous literature regarding the prevalence of PTSD among refugees and demonstrated that men with PTSD also usually had anxiety and depression. Interestingly, no correlation was found between the severity of the physical injury and the mental health of these men—indicating that all refugees, regardless of physical ailments, should be tested for mental health disorders. The presence of chronic pain, on the other hand, was associated with an overall lower level of mental health.11

Despite the overwhelming evidence that treatment of mental health issues is essential to the well-being of refugees, there are several challenges to achieving equitable mental health care for refugees. In Jordan, for example, addressing the physical health of refugees is already a public health issue, and now the nation is running out of resources. Since 2011, the country’s health sector has been straining to care for a huge influx of Syrian refugees. The Ministry of Health spent about US $53 million on care to refugees between January and April of 2013, with only US $5 million provided in support by UN agencies.12 Under these conditions, receiving extra support for mental health treatment seems nearly impossible, but it is essential.

Among some, there is also considerable ambiguity surrounding the mental illnesses of refugees and debates about whether they should even be considered diseases. Many authors debate the accuracy of labeling refugees who are suffering psychologically from trauma as mentally ill. These individuals suggest that emotional suffering from severe trauma should be seen as a normal reaction to refugees’ catastrophic experiences.13 The danger of mental illness exists when refugees’ immediate concerns are not addressed and these emotions later develop into severe mental illnesses. Immediate mental health services are key to restoring basic psychological functioning and supporting the wellbeing of all.

Another challenge with refugee mental illness treatment is the cultural stigma that is often associated with mental illness, and the lack of adequately trained local doctors. Many foreign psychological doctors do not fully understand the cultural idioms and methods through which suffering is expressed in refugee communities. Western-style clinical interventions are often culturally inappropriate and do not adequately address the mental health needs of refugees.

Ratiba Awad pictured with her three children, Ouday, Ahraa, and Batoula (5 years, 4 years, and 7 months old resepctively). They live in an old cow shed with 20 other Syrian refugees who were also forced to abandon their homes during the Syrian war. Source: Trocaire

Similarly, well-intentioned international humanitarian help is only marginally effective, due to several key factors: First, this international aid is not sustainable; it promotes community reliance on the expertise of foreign organizations. Second, it hinders local capacity building, which is an important long-term solution to the mental health crisis. Instead of directly serving refugees, international aid workers should train local doctors in mental health care. These local doctors may help victims feel more comfortable in talking about and expressing their struggles, considering their similar cultural and religious backgrounds. Also, they may better understand the religious taboos and cultural stigma associated with mental health. Jordan currently lacks its own trained mental health practitioners; training such doctors is vital to any solution. Additionally, a fear of victimization makes refugees reluctant to share traumatic experiences with a mental health practitioner. A community-based approach can help ameliorate this challenge, especially among a population that has experienced similar atrocities.

Several specific approaches have been designed to treat refugees’ mental health challenges. One model calls for a holistic method of treatment that addresses interwoven physical and psychological problems in conjunction. This approach lessens the stigma associated with treatment of mental health illnesses as a unique and separate process from treatment for physical ailments.

A second approach emphasizes practical treatments. This method aims to create a new normal for refugees, who may simply require help developing a system or a routine in order to feel better. In this approach, volunteers and practitioners help promote practical outcomes such as access to employment and education.14 Considering that 25 percent of Syrian women are the head of their household, women’s education is vital for both these women and their children. For some individuals, emotional therapy and assistance with practical matters is sufficient to ameliorate their condition. Some advocates of this approach suggest that the Zaatari camp set up classes geared towards teaching women basic skills to help them earn income, such as cooking, sewing, and making crafts or household objects. Benefits of these classes include: restoring a routine to women’s lives, which is essential to mental health healing; helping them regain a purpose in life, and empowering them to be self-sufficient by awarding them for their hard work.

Similar strategies can be used to promote children’s mental health. Simply recreating social relationships and establishing routines is deeply helpful. This is why school is such an important factor for chilren’s healing. The Center for Victims of Torture (CVT) estimates that 2.5 million Syrian youth still face restricted access to education. A better education system with more funding is needed in order to achieve universal education in Syria. The CVT, whose clinics in Amman and Zarqa have been fairly successful in establishing a “new normal” for refugees, have a very clear objective in mind: “to facilitate a shift in self-image from passive victim to active survivor.”15 Although this shift is not easy to incite in devastated refugees, change is possible.

Although almost 50 percent of refugees suffer from mental health disorders, it is important not to assume that an entire refugee population is mentally disturbed, as psychiatric morbidity and psychological complications depend on the nature and time span of the crisis. Additionally, the prevalence of mental health disorders is based on sociocultural factors and other environmental parameters.2 Syrians who are now arriving in Jordan, after witnessing years of atrocities committed by Assad regime and, more recently, ISIS, may be more mentally distraught than refugees that fled the country earlier on. The quick provision of care for such individuals is vital.

Furthermore, treatment efficacy increases not only when the local community is involved, but also when the international community is cooperating. There are many organizations working in the Zaatari camp: the UNHCR, the Jordan Health Aid Society, the WHO, and the Red Cross, among many other international and local groups. In order for mental health and physician training programs to be successful, it is important for these organizations to cooperate, share information, and pool resources.

Recently, there has been a significant increase in mental health awareness, as evidenced by the tremendous number of organizations that specialize in mental health care. The stigma associated with mental health care has also significantly subsided. However, the road toward success is still long. The basic factors essential to mental health—education for children, employment for adults, comfortable and sanitary living conditions—are not yet available to many Syrian refugees. Moreover, mental health care facilities and local specialists are lacking. Jordan needs to build a program, with the help of expert international organizations, to train physicians in mental health care and to establish a program to reverse the tide of mental health ailments among the Syrian refugee population.

Farah Al Hadid is a sophomore in Jonathan Edwards College. She is an undeclared major. She can be contacted at farah.alhadid@yale.edu.